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07/19/2002 08: 18 2094683433 FIFTH FLLLrc <br /> WELL PERMIT APPLICATION FuRM SITE <br /> SAN JOAQUIN COUNTY T�—'~L\' D <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) _`�WLL' ' ' . <br /> 304 E_ Weber, Third Floor, Stockton, CA., 95202 NOV 1 3 2002 <br /> (209) 468.3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIRONMENT HEALTH <br /> H�EAC <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work dssrAbed. This application is made <br /> Joaquin County Development Tillie,Chapter 9-1115.3 and the Standards of San Joaquin County Eivironmental Health Department <br /> nn Assessors <br /> WELLLocation Cross Street cn�- City T's' Zlp ' 20 Parcel# I61-Ors0-v3 <br /> PROPERTYOwner �-Ytvs,,_t� Address '?`+41 L%\jx �Igm City r Zip 1S-V-G Phone# Z - ��i3' •� <br /> C•57 Contractor Address .22c- t,j City :;.,.,.i�Zip�� Lich�at,-i3y Phone# ;'so -=�`� <br /> Consultant/Sub Contractor, �.0 F!Xtr'�o-J Address 5Cn . ,` ;;r _City :� UcV Phone# tib 8��=sty <br /> GIS Coordinates:X .Y Township Range Section— <br /> WORK- <br /> TO <br /> ectionWOR TO BE PERFORMED: <br /> W WELL BOP.ING(CFT,4gaPROBE,HYDP,OPUNCH,HAND-HUGE OTHER') a DESTRUCTION(choose type below) <br /> 0 SOIL BOKINU 17 OVER-BORE <br /> n WELL 4p PRESSURE GROUT <br /> 'Other. Grout Specifications: <br /> COMMENTS: QIP-.\ -1q <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> Q MONITO?ING n HOLLOW STEM DIA.OF BOREHOLE1,7r MULTIPLE CASINGS?p YES B;,N0 WELL CASING DIA: <br /> n EXTFACTION n AIR HAMMER/DRIVEN CASING THICKNESS N-0 TYPE OF CASING: I1 STEEL 0 PVC []OTHER: <br /> n VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: I]AUGERS &HOSE <br /> 1�1��AIR SPARGE p PUSH POINT GROUT SEAL PUMPED: p Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> fr501L PORING rl HAND AUGER GROUT SPECIFICATIONS: F�sJ;ct>.�E �C <br /> C;EpvPpt$c RCC, <br /> n OTHER:_ ['rOTHER tin..,n APPROX. BORING DEPTH 0S U 0 BOLTED TRAFFIC BOX or p STOVE PIPE <br /> _ CONDUCTOR CASING PROPOSED? C (if YES,list specifications here): <br /> 'COMMENTS: )C3� ,�Fr�r -tJVcSSSGf.Cst�J <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS, <br /> C,a1_I_THE UNIT IV INSPFCTOR ata WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Orriina c S, R I S and, Regulations, and all applicable California State Laws. <br /> Signed x r - "I elCompany CA0M=A\_ trA <br /> Print Name (rt�LDate <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted 6 Date Issued--�f-'—Ff Area C tl4A 6ZCt? <br /> Grout Inspection By Date It 0 L Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS!CONDITIONS: <br /> ACCOUNTING ONLY: AID# cera <br /> PE CODES FEE INFO AMOUNT REMr1TED CHECK# REC'D BY DATE PERMIT!SERVICE REQUEST# INVOICE <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc 1/25/02 <br />